Lung cancer non small cell staging prognosis treatment
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Lung Cancer Non-Small Cell Staging/Prognosis/Treatment. Oncology Teaching October 14, 2005 Lorenzo E Ferri . Lung Cancer. Highest cancer death rate for men and women. Canadian Cancer Statistics 2004. Lung Cancer – Pathology. Non-Small Cell Squamous Cell Carcinoma Adenocarcinoma BAC

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Lung cancer non small cell staging prognosis treatment l.jpg

Lung CancerNon-Small CellStaging/Prognosis/Treatment

Oncology Teaching

October 14, 2005

Lorenzo E Ferri


Lung cancer l.jpg
Lung Cancer

Highest cancer death rate for men and women



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Lung Cancer – Pathology

  • Non-Small Cell

    • Squamous Cell Carcinoma

    • Adenocarcinoma

    • BAC

    • Large Cell

  • Small Cell

  • Neuroendocrine (Carcinoid, Large cell NE, small)


Staging l.jpg
Staging

  • Staging should provide prognosis and dictate management

  • TNM Classification universally accepted


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T status – T1

  • 3 cm or less, completely covered by pleura, does not involve main bronchus


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T Status – T2

  • > 3cm

  • Visceral pleura

  • Main bronchus but > 2cm from carina

  • Atelectasis but not complete lung


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T status – T3

  • Chest wall

  • Diapragm

  • Mediastinal pleura

  • Pericardium

  • Main bronchus <2cm to carina

  • Complete atelectasis


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T Status – T4

  • Carina

  • Vertebrae

  • Great Vessel

  • Esophagus

  • Heart

  • Separate tumour nodule in same lobe

  • MALIGNANT pleural effusion



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N Status

  • N0 – no regional LN metastases

  • N1 – LN mets in ipsilateral peribronchial and/or intrapulmonary

  • N2 – ipsilateral mediastinal or subcarinal

  • N3 – contralat mediastinal or supraclavicular nodes


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M Status

  • Common distant sites sites include

    • Brain, bone, liver, adrenal

  • Two nodules in same lung


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Stage I

  • 1A – T1 N0

  • 1B – T2 N0


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Stage IIA

  • T1 N1


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Stage IIB

  • T2 N1

  • T3 N0


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Stage IIIA

  • T1-3 N2

  • T3 N1


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Stage IIIB

  • T0-3 N3

  • T4 N0-3


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IA

IB

IIA

IIB

IIIA

IIIB

IV

60-75%

50-60%

50-60%

40-50%

15-30%

5-10%

0-5%

5 Year Survival

  • Overall 5 year survival = 15% (no change in 3 decades)

Mountain 1997, Rami-Porta 2000, Naruke 1988


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Survival

Survival by Pathologic Stage

Survival by Clinical Stage

MD Anderson 1975-1988


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Is all Stage IIIA (N2) the same?

  • Single vs multiple station

  • Bulky vs non-bulky

  • Station 5/6 in LUL cancer

  • Nodal vs extra-nodal disease


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Staging Investigations – non invasive

  • History and Physical! –hoarseness (T3 or N2) supraclavicular nodes (N3)

  • CXR – Size (rough), chest wall (T3), effusion (T4)

  • CT Chest/upper Abdo

    • T status – accurate

    • N status (>1 cm= 70% +, <1cm=7% +)

    • M status – adrenal, liver, lung, bone


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Staging Investigations – non invasive

  • MR – for T4 and M1

    • thorax – not routine – for Pancoast

    • Brain – asymptomatic patients have brain mets in less than 3% Hillers et al Thorax 1994

  • Bone Scan – asymptomatic patients have mets in less than 5%


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PET/CT

  • Technology is evolving

    • Allows for “one step” extrathoracic staging

    • Independent predictor for survival (low SUV)

    • What about mediastinum?

      • NPP must be very high if invasive staging is to be avoided

    • NPP=98% in a recent study (Pozo-Rodriguez JSO 2005)

Not good for BAC, small lesions <0.5 cm


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PET/CT

Does this need pathologic confirmation?


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Invasive StagingBronchial, Mediastinal and Pleural

  • Bronchial  Bronchoscopy – for proximal lesions (T3 vs T4)

  • Pleural 

    • Throracentesis – 60-65% accurate

    • Pleuroscopy and biopsy – more than 95%


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Post-obstructive effusion

Are all effusions associated with known

lung cancer malignant?


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Mediastinal Staging - Invasive

  • CT and PET/CT – better but not perfect for mediastinal nodes

  • Mediastinoscopy is the gold standard!

    • Assesses N2 and N3


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Endoscopic BiopsyEUS FNA TBNA


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What is really needed?

  • Do we need to invasively assess N2 disease in everyone?

    • Small peripheral lesion (esp SCC and BAC) have a low rate of mediastinal mets (1 cm=10%, 3 cm =25%)

    • CT/PET accuracy is improving

    • TBNA and EUS often obviate the need for M-scope

Institution specific – U of T – everyone gets a M-scope

McGill and rest of N.A. - selective


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Treatment

  • Stage IA – Lobectomy (VATS vs Thoracotomy)

  • Stage IB-IIB - Lobectomy + adjuvant Cx

    • Pancoast (T3N1) – neoadjuvant chemorads (EP 2cycles with 45 Gy)

  • Stage IIIA –

    • T3N1 (resected) – adjuvant Cx

    • N2 disease  ???

      • Traditionally a non-surgical disease BUT…..

      • Neoadjuvant (Int 0139) - no Difference, but 27% vs 20% 5-yr survival - Albain et al ASCO 2005


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Treatment

  • Stage IIIB – definitive CxTx, BUT….

    • Not all T4s are equal

      • T4N0-1 – aorta, vertebra, all other major vessels have been resected with reasonable 5 year survival (20-30%) Rendina JTCVS 1999


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Treatment

  • Stage IV

    • Palliative – median survival approx 6 months

    • Malignant effusion – if symptomatic

      • Thoracentesis 

        • if no improvement think lymphangetic spread, PE, etc

        • If symptomatically improved

          • if lung expands  Pleurodesis

          • If lung trapped  pleural drainage (tenkhoff vs repeated taps)


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